Transcript Slide 1
LINKING PEOPLE WITH
ALZHEIMER’S DISEASE AND
OTHER DEMENTIAS TO
SUPPORT, INFORMATION AND
OTHERS WHO CAN HELP
Serving People with Dementia
FIRST LINK ™
A
referral program that will:
link people diagnosed with dementia to
support, information and services that
can help.
assist caregivers of people with
dementia by linking them to services as
early as possible in the disease process.
BENEFITS FROM PARTICIPATING
IN FIRST LINK ™
People
with dementia will have
increased health information enabling
them to make informed decisions about
their health care needs.
People
with dementia and their
caregivers will have
more information about dementia, health
services and non-medical community
services.
BENEFITS FROM PARTICIPATING
IN FIRST LINK ™
Caregivers
will
have increased knowledge, skills and
confidence.
be encouraged to develop self care
strategies.
FIRST LINK ™ REFERRAL RESOURCES
To
First Link ™
Referral by physicians and other health
care professionals, diagnostic and
treatment services and community
service providers.
Self referral by the person with
dementia or their family.
FIRST LINK ™ REFERRAL RESOURCES
To
Other Services
The Alzheimer Society will provide
information about primary health and
community-based non-medical services.
Alzheimer Society services such as
Safely Home™ - the Alzheimer
Wandering Registry.
FIRST LINK ™ SUPPORT SERVICES
The
Alzheimer Society provides
phone conversations
personal appointments
support groups for
people with dementia
caregivers – in person and distance
telephone groups
FIRST LINK ™ INFORMATION SERVICES
Alzheimer
Society services include
Print material
Website
Information sessions
Caregiving: Building Your Team
Caregiving with Confidence
is your link to
Help for Today and
Hope for Tomorrow
Serving People with Dementia
Click to edit Master
Winnipeg Regional Health
Authority (WRHA):
GERIATRIC MENTAL
HEALTH TEAMS
Why Change?
Improve Access
Reduce Duplication
Develop linkages
Improve system efficiency
Bed Capacity
SITE
PAST
Bethania Mennonite 9 behavioural treatment
Personal Care Home
Deer Lodge Centre
10 “PCH Cottage”
12 assessment & rehab
0
36 dementia care personal
47 specialized dementia
care
Riverview Health
Centre
FUTURE
10 behavioural treatment
60 dementia care personal care
assessment & rehab
& behavioural care
10 Acquired Brain Injury
Rehab
60 dementia/behavioural
care
Seven Oaks General
Hospital
19 Geriatric Psychiatry
19 Geriatric Psychiatry
Geriatric Mental Health Service
Delivery Model:
June 1st, 2006
6 teams- 6 catchments
Service to PCH & Community
Geriatric Psychiatrist on each team
1 Central Intake
Consistent response to referrals
Data Entry done daily- retrieval/ stats
Geriatric Mental Health Service
Delivery Model:
Information Sheet for public
65 or older with 1st onset Mental Illness
65 or older with history of Mental Illness-disease and
aging process- GMH service
65 or younger with behaviour/MH symptoms or
cognitive issues related to aging
Geriatric Mental
Health (GMH):
CENTRAL INTAKE – GMH & GPAT
DLC - 8:00 a.m.-4:00 p.m.
Phone: 982-0140 or Fax: 982-0144
Open Referral Process- phone/ fax/ mail
GMH Referral Form
GMH Intake:
Database
entry-
Flag if known to GMH or GPAT & eventually DH
Based
on client address- faxed to appropriate
team the same day
GMH Teams:
River East & Transcona (ARE)
St. James-Assiniboia/Assiniboine South (DLC)
River Heights/Fort Garry (RHC)
St. Boniface/St. Vital (Tache)
Inkster/Seven Oaks (1050 Leila)
Point Douglas/Downtown (DLC)
Each team consists of 2 clinicians + Geriatric
Psychiatrist.
GMH Service:
Provide
timely geriatric mental health
assessment
Recommendations (Geriatric Psych.)
Short-term intervention
Connect with service to clients in the
Community or recommend care in Personal
Care Homes
Response Times:
GOAL:
Not a Crisis Response Team
Non-Urgent – contact- 3 days, visit in 10 days
Urgent – contact-1 day, visit in 3 days
Clinician contact made to determine level of
risk/ appropriate service & schedule
appointment
Weekly Team Reviews:
Team
Reviews scheduled with Geriatric
Psychiatrist -discussion of cases
Care Planning/ problem-solving/ resources
Case Closure:
when
linked with services required
when issues stabilized/ improve
when admitted to hospital-not expected to
return
Winnipeg Regional Health Authority
(WRHA):
Geriatric Program
Assessment Teams (GPAT):
Geriatric Program
Assessment Teams (GPAT):
•
Outreach program within the WRHA
Rehab & Geriatrics Program
•
Developed in 1999 & modeled from
Ottawa/Carlton Geriatric Outreach Teams
•
Started with 2 teams of 3 clinicians in
each team then grew to 5 teams of 3
clinicians by Sept. ‘99
GPAT (cont’d)
Each clinician receives 12 weeks of specialized geriatric
training
This enables each clinician to complete a medically based
multidimensional assessment in the client’s home assessing
the following:
physical, functional, cognitive, emotional, psychosocial, mobility,
GI/GU, safety, polypharmacy.
GPAT Emergency Room
(ER) Involvement
In Aug. ’04 ER Task force made recommendations
about GPAT as follows:
GPAT clinicians will have a standard approach in assessment
process in all ER’s in Wpg. to improve care to geriatric clients
GPAT clinicians will prioritize the ER in their caseload
GPAT will refer directly to Home Care to decrease wait times
for clients’ services in the community
GPAT response to ER Task Force
Restructured 5 teams to 6 to service 6 ER’s in Wpg. in mid
Nov. ‘04
Researched database information on clients over age 65 in
the community and in Personal Care Homes in 12
community areas
Developed new catchment boundaries for 6 teams with no
additional resources…some 2 & 3 person teams with
Geriatrician
Geriatric Program Assessment
Teams (GPAT):
There are 6 teams across the city of Winnipeg
Concordia
Deer Lodge Center
Health Science Center
Riverview
St. Boniface
Seven Oaks Hospital
Each Team consists of 2-3 disciplines and a Geriatrician +
.6 float
BN, BPT, BOT, BSW
GPAT: cont’d
After
the clinician has completed the
assessment they review with the Geriatrician
and team.
Clinicians will make referral to community
resources & recommendations to family MD
with geriatrician input.
GOALS
To ensure the “right care, in the right place
at the right time”.
Maintain
functional ability in their home
Partner with community caregivers for
management to prevent hospital admission
(Home Care, Day Hospital, Age and Opportunity
friendly visitor, CNIB)
GOALS (Cont’d)
Facilitate
the transfer of appropriate clients to
geriatric medicine and rehab units.
Assist
in-patient teams with the discharge
planning of complex, frail, elderly (ER).
Provide
care management/ follow-up, short term
intervention
POPULATION SERVED
The
frailest, at-risk elderly, 65+ years.
Complex
health concerns affecting their ability
to function.
Geriatric
Issues: mobility, ADL problems,
Toileting, Confusion, Depression, Social
Support, Medication problems
REFERRALS
Open
Referral Process:
Anyone can refer to our service:
Family member, friend, bank manager, Home Care,
caregiver, & physicians, etc.
To refer to GPAT, either call the
Central Intake Line at 982-0140 or
fax Central Intake Form to 982-0144.
Contacts:
Marlene Graceffo, Rehab & Geriatrics Regional
Manager
831-2537
Lois Stewart-Archer, Geriatric Mental Health Regional
CNS
831-2179
Jill Moats, Rehab & Geriatrics Regional Educator
831-2150
Questions
PRIME
A Health Centre for Seniors
Who does PRIME serve?
Targets
community-dwelling seniors who
are:
Not functioning well in the community
At risk of institutionalization
Wish to remain in the community
PRIME Goals
1.
2.
3.
4.
Maintain seniors in the community
Enhance care coordination and
service delivery for the frail elderly
Personal care home placement
Hospital/Emergency use
PRIME
Umbrella of Care
Case
Manager
Day Centre
Primary Health Clinic
After hours support
Inpatient beds
Day Centre
Transportation
Personal
care/ grooming/ personal laundry
Recreational and social activities
Rehabilitation /exercises
Health promotion activities
Lunch meal
Primary Health Clinic
Transfer
of care to PRIME physician
Coordination of on-site & off-site
appointments
Medications provided weekly
After hours support
Evening
and weekend nurse
Home visits and telephone response
Provincial Health Contact Centre
Facilitate Access to
Inpatient Beds
Treatment
Intensive
rehabilitation
Emergency respite
Assessment
Program Model & Outcomes
Modelled
on Edmonton CHOICE and
U.S.A. PACE
Edmonton CHOICE results:
emergency visits reduced by 62.9%
inpatient days reduced by 70%
ambulance claims reduced by 51.5%
Edmonton Outcomes (cont’d)
High
participant & family satisfaction
Maintained health status of participants
Slowing of health decline
Improved quality of life
Support community living
PRIME
A Health Centre for Seniors
Judy
Ahrens-Townsend
Regional Manager
Phone: 831-2192
Email: [email protected]